Pneumonia The Forgotten Killer of Children

PNEUMONIA
KILLER OF CHILDREN
THE FORGOTTEN
PNEUMONIA
THE FORGOTTEN KILLER OF CHILDREN
UNICEF/HQ05-0837/Josh Estey
ACKNOWLEDGEMENTS
This report was prepared by Tessa Wardlaw (UNICEF), Emily White Johansson (UNICEF) and Matthew Hodge, and produced by UNICEFs Division of Communication. Many people provided valuable contributions to this report. Important overall guidance and advice were provided by Robert Black, Cynthia Boschi-Pinto, Jennifer Bryce, Harry Campbell, Gareth Jones, Orin Levine, Elizabeth Mason, Kim Mulholland, Shamim Ahmad Qazi, Igor Rudan, Peter Salama, Eric Simoes, Nancy Terreri, Pascal Villeneuve and Neff Walker. Key data, information and materials were contributed by Kim Mulholland (pathogen-specific causes), Igor Rudan (incidence estimates), Kenji Shibuya with Doris Ma Fat (cause-specific mortality estimates) and Neff Walker (costing estimates), and WHO (country-level pneumonia mortality estimates). Additional inputs were provided by Nyein Nyein Lwin and Diakhate Ngagne.
Pneumonia: The forgotten killer of children The United Nations Childrens Fund (UNICEF)/World Health Organization (WHO), 2006. All rights reserved. UNICEF and the World Health Organization welcome requests for permission to reproduce or translate their publications whether for sale or for non-commercial distribution. Applications and enquiries should be addressed to UNICEF, Division of Communication, 3 United Nations Plaza, New York 10017, USA (Fax: +1 212 303 7985; E-mail: nyhqdoc.permit@unicef.org) or to WHO Press, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland (Tel.: +41 22 791 3264; Fax: +41 22 791 4857; E-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (Fax: +41 22 791 4806; E-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of UNICEF or the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by UNICEF or the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by UNICEF and the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall UNICEF or the World Health Organization be liable for damages arising from its use. UNICEF/WHO, Pneumonia: The forgotten killer of children, 2006 ISBN-13: 978-92-806-4048-9 ISBN-10: 92-806-4048-8
Cover photo: UNICEF/HQ05-0531/Rachel Donnan
TABLE OF CONTENTS
Introduction ...............................................................................................................4
Background on pneumonia......................................................................................6 What causes pneumonia? ...............................................................................7 What are the symptoms of pneumonia? .......................................................7 How is pneumonia diagnosed? ......................................................................8 How is pneumonia transmitted?.....................................................................8 Why are children vulnerable? .........................................................................8 How is pneumonia prevented?.......................................................................9 How is pneumonia treated? ............................................................................9
Pneumonia: Who suffers, Who dies?.....................................................................10
Levels and trends in knowledge and treatment ...................................................14 Recognition of pneumonias danger signs ..................................................16 Care-seeking behaviour .................................................................................16 Antibiotic treatment for pneumonia.............................................................20
Key actions needed to reduce pneumonia deaths...............................................22
The cost of reducing pneumonia deaths ..............................................................28
Pneumonia: A forgotten pandemic .......................................................................29
Appendix..................................................................................................................30
References ...............................................................................................................31
Statistical tables ......................................................................................................34
PNEUMONIA KILLS MORE CHILDREN THAN ANY OTHER ILLNESS MORE THAN AIDS, MALARIA AND MEASLES COMBINED. OVER 2 MILLION CHILDREN DIE FROM PNEUMONIA EACH YEAR, ACCOUNTING FOR ALMOST 1 IN 5 UNDERFIVE DEATHS WORLDWIDE. YET, LITTLE ATTENTION IS PAID TO THIS DISEASE.
This report examines the epidemiological evidence on the burden and distribution of pneumonia and assesses current levels of treatment and prevention. The results are sobering: Only about 1 in 5 caregivers knows the danger signs of pneumonia; only about half of children sick with pneumonia receive appropriate medical care; and, according to the limited data available, less than 20 per cent of children with pneumonia received antibiotics, the recommended treatment. Effective interventions to reduce pneumonia deaths are available, but reach too few children. Scaling up treatment coverage is possible, and at relatively low cost. Estimates suggest that if antibiotic treatment were universally delivered to children with pneumonia, around 600,000 lives could be saved each year, at a cost of $600 million.1 Furthermore, the number of lives saved could more than double to 1.3 million if both prevention and treatment interventions to reduce pneumonia deaths were universally delivered.
UNICEF/HQ05-0837/Josh Estey
INTRODUCTION
Our hope is that this report will raise awareness about this neglected disease and will serve as a call to action to reduce child deaths from pneumonia.
BOX 1
GLOBAL GOALS AND TARGETS FOR REDUCING CHILD MORTALITY AND PNEUMONIA DEATHS
Reducing child mortality is one of the eight Millennium Development Goals (MDGs), which are the worlds timebound targets for reducing poverty in its various dimensions by 2015. Specifically, Goal 4 calls for reducing underfive mortality by two thirds between 1990 and 2015. Achieving the MDG on child mortality will require urgent action to reduce childhood pneumonia deaths, which account for 19 per cent of all under-five deaths.
COUNTING UNDER-FIVE DEATHS FROM PNEUMONIA

Figure 1 presents the global distribution of the primary causes of all under-five deaths and shows that pneumonia kills more children than any other illness accounting for 19 per cent of all under-five deaths (see the Appendix for more detailed information on these estimates of cause-specific mortality ). This figure, however, does not include deaths due to pneumonia during the first four weeks of life, the neonatal period. It has been estimated that 26 per cent of neonatal deaths, or 10 per cent of all under-five deaths, are caused by severe infections during the neonatal period. And a significant proportion of these infections is caused by pneumonia/sepsis (sepsis is a serious blood-borne bacterial infection that is also treated with antibiotics). If these deaths were included in the overall estimate, pneumonia would account for up to 3 million, or as many as one third (29 per cent), of under-five deaths each year.
FIGURE 1 PNEUMONIA IS THE LEADING KILLER OF CHILDREN WORLDWIDE

Global distribution of cause-specific mortality among children under five, 2004 Neonatal diarrhoeal diseases 1% Neonatal other 2% Neonatal tetanus 2% Congenital anomalies 3% Birth asphyxia 8% Preterm birth 10% Neonatal severe infections (mainly pneumonia/sepsis) 10% Measles 4% Injuries 3% AIDS 3% Pneumonia 19% Diarrhoeal diseases 17% Others 10% Malaria 8%
Millennium Development Goals

Goal 4: Reduce child mortality Reduce by two thirds, between 1990 and 2015, the under-five mortality rate.
A World Fit for Children Plan of Action: Goals, Strategies and Actions
Reduce by one third deaths due to acute respiratory infection between 2000 and 2010 (section III.B.1, para. 37).
Undernutrition is implicated in 53% of all deaths among children under five.
FIGURE 2 PNEUMONIA IS A MAJOR CAUSE OF CHILD DEATHS IN EVERY REGION

% under-five deaths due to pneumonia, by UNICEF region, 2004
PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN
Acute respiratory infections can occur in any part of the respiratory system, from the middle ear to the nose to the lungs.2 Pneumonia is a severe form of acute lower respiratory infection that specifically affects the lungs. The lungs are composed of thousands of tubes (bronchi) that subdivide into smaller airways (bronchioles), which end in small sacs (alveoli). The alveoli contain capillaries where oxygen is added to the blood and carbon dioxide is removed. When a person has pneumonia, pus and fluid fill the alveoli in one or both lungs, which interferes with oxygen absorption, making breathing difficult. Most acute respiratory infections result in mild illnesses, such as the common cold. But in vulnerable children, infections that begin with mild symptoms may sometimes lead to more severe illnesses, such as pneumonia especially when they coincide with other illnesses like diarrhoea or malaria.
BACKGROUND
ON PNEUMONIA
UNICEF/HQ02-0513/Ami Vitale
BOX 2
WHAT
causes PNEUMONIA?
TERMINOLOGY USED IN THIS REPORT

Acute respiratory infection: This includes any infection of the upper or lower respiratory system, as defined by the International Classification of Diseases.a Acute lower respiratory infections affect the airways below the epiglottis and include severe infections, such as pneumonia. Pneumonia accounts for a significant proportion of the disease burden attributed to acute lower respiratory infections. Pneumonia: The term pneumonia as used in this report refers to suspected pneumonia. A suspected case of pneumonia is identified by its clinical symptoms, since diagnostic confirmation using radiography or laboratory tests is usually unavailable in resource-poor settings. All children under five years of age with suspected pneumonia, therefore, are defined as having cough and fast or difficult breathing. Suspected pneumonia cases are further classified as either severe or non-severe (see Box 5 on page 24 for more detail about classifications ). b, c
Data on the pathogen-specific causes of pneumonia are limited, and available information is often difficult to interpret. It is known that the bacterial pathogen Streptococcus pneumoniae is the leading cause of severe pneumonia among children across the developing world. Bacteria also contribute to non-severe pneumonia cases, but to a lesser extent, and more cases are probably of viral origin. Another major cause is the bacterial pathogen Haemophilus influenzae type b (Hib). Other pathogens include important viruses, less common bacteria and fungi. However, more specific information for the aetiology of childhood pneumonia is not available. Research is urgently needed to better describe the distribution of pneumonia by its causes. Knowing which pathogens lead to pneumonia is critical for guiding treatment and policies.
WHAT ARE THE
symptoms OF PNEUMONIA?
Children with pneumonia may have a range of symptoms depending on their age and the cause of the infection. Bacterial pneumonia usually causes children to become severely ill with high fever and rapid breathing. Viral infections, however, often come on gradually and may worsen over time. Some common symptoms of pneumonia in children and infants include rapid or difficult breathing, cough, fever, chills, headaches, loss of appetite and wheezing. Children under five with severe cases of pneumonia may struggle to breathe, with their chests moving in or retracting during inhalation (known as lower chest wall indrawing). Young infants may suffer convulsions, unconsciousness, hypothermia, lethargy and feeding problems.3
FIGURE 3 PATHOGEN-SPECIFIC CAUSES OF SEVERE PNEUMONIA CASES

Pathogen Distribution of severe pneumonia cases by cause Discussion
Streptococcus pneumoniae (bacterium) Haemophilus influenzae (bacterium)

Other important pathogens
Leading cause
S. pneumoniae is the leading pathogen in almost all studies from around the world. Recent vaccine trial data indicate that in Africa it may be responsible for over 50% of severe pneumonia cases, and probably a higher proportion of fatal cases. This proportion may vary in different parts of the world.
Most disease is caused by type b (Hib). Vaccine studies from Bangladesh, Chile and the Gambia suggest that Hib causes around 20% of severe pneumonia cases, although the proportion may vary in different parts of the world. These pathogens include important viruses such as respiratory synctial virus (RSV) and influenza; other bacteria, such as Staphylococcus aureaus and Klebsiella pneumoniae; and the fungus Pneumocystis jiroveci (PCP), which is particularly important in young children with AIDS (see Box 3, page 8 ). PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN
Major cause
Less common
BOX 3
PREVENTING HIVRELATED PNEUMONIA IN CHILDREN
Pneumonia is a common opportunistic infection among HIVpositive children worldwide. The pneumonia that is found in people with HIV is caused by the fungal organism P. jiroveci and is commonly referred to as PCP. Recent evidence from Malawi, South Africa, Thailand and Zambia show that PCP causes at least 1 of every 4 deaths among HIV-positive infants under the age of one.a It is important to note, however, that while PCP has become an increasingly significant cause of death among HIV-positive children, it causes only about 5 per cent of pneumonia deaths among all children worldwide.b WHO and UNICEF recommend cotrimoxazole prophylaxis for all HIV-positive children, as well as for infants born to HIVinfected mothers, in order to prevent them from developing pneumonia. c Clinical trials in Zambia show a significant and sustained reduction in hospital admission and mortality rates among sick HIV-positive infants receiving cotrimoxazole compared to those in the placebo group.d This intervention has been part of the routine-care package for HIV-positive children and adults in many developed countries since the early 1990s.e Providing cotrimoxazole (and/or antiretroviral treatment) by 2010 to 80 per cent of children in need is one of the main objectives of UNICEFs global campaign Unite for Children. Unite against AIDS.
HOW IS PNEUMONIA
diagnosed?
Chest X-rays and laboratory tests are used to confirm the presence of pneumonia, including the extent and location of the infection and its cause. But in resource-poor settings without access to these technologies, suspected cases of pneumonia are diagnosed by their clinical symptoms. Children and infants are presumed to have pneumonia if they exhibit a cough and fast or difficult breathing (see detailed guidelines in Box 5, page 24 ).4 Caregivers, therefore, have an important role to play in recognizing the symptoms of pneumonia in children and seeking appropriate medical care as necessary.
HOW IS PNEUMONIA
transmitted?
Pathogens causing pneumonia may reach the childs lungs through different routes. Although information on the pathogenesis of childhood pneumonia is limited, it is widely believed that common bacterial pathogens causing pneumonia are often already present in a childs nose or throat and are then inhaled into the lungs, causing infection.5 Pathogens may also be spread through contaminated air droplets or may result from blood-borne infections. During or shortly after birth, babies are at higher risk of developing pneumonia from coming into contact with organisms in the birth canal or from contaminated substances contacted during delivery.
WHY ARE CHILDREN
vulnerable?
A healthy child has many natural defences that protect its lungs from the invading pathogens that cause pneumonia. However, children and infants with compromised immune systems have weakened defences. Undernourished children, particularly those not exclusively breastfed or with inadequate zinc intake, are at higher risk of developing pneumonia. Similarly, children and infants suffering from other illnesses, such as AIDS or measles, are more likely to develop pneumonia. Environmental factors, such as living in crowded homes and exposure to parental smoking or indoor air pollution, may also have a role to play in increasing childrens susceptibility to pneumonia and its severe consequences.6
HOW IS PNEUMONIA
prevented?
Preventing children from developing pneumonia in the first place is essential for reducing child deaths (see Box 7 , page 26 ). Key prevention measures include promoting adequate nutrition (including breastfeeding and zinc intake), raising immunization rates (see Box 8, page 27 ) and reducing indoor air pollution.7 HIV-positive children are less likely to develop HIV-related pneumonia if they are given a daily dose of cotrimoxazole (see Box 3, page 8 ).8 Recent research also suggests that hand washing may play a role in reducing the incidence of pneumonia.9
HOW IS PNEUMONIA
treated?
Prompt treatment of pneumonia with a full course of appropriate antibiotics is lifesaving. UNICEF and WHO have published guidelines10 for diagnosing and treating pneumonia in community settings in the developing world (see Box 6, page 25 ). This approach is proven, affordable and relatively straightforward to implement.11 Cotrimoxazole and amoxicillin are effective drugs against bacterial pathogens and are often used to treat children with pneumonia in developing countries. Infants under two months with signs of pneumonia/sepsis are at risk of suffering severe illness and death more quickly than older children, and should be immediately referred to a hospital or clinic for treatment (for full discussion, see Box 5, page 24).12 Treatment regimens will need to be chosen based on their efficacy in local settings. Some areas may have high levels of resistance to certain antibiotics, rendering those drugs less effective for treating pneumonia (see Box 4, page 21 ). Other areas may have large numbers of high-risk groups, such as undernourished or HIV-positive children, and may need to adapt their treatment strategies accordingly (see Box 3, page 8 ).
UNICEF/HQ00-0422/Alejandro Balaguer
It is estimated that more than 150 million episodes of pneumonia occur every year among children under five in developing countries, accounting for more than 95 per cent of all new cases worldwide. Between 11 million and 20 million children with pneumonia will require hospitalization, and more than 2 million will die from the disease. It is also important to note that incidence of pneumonia among children decreases with age.13 South Asia and sub-Saharan Africa combined bear the burden of more than half of the total number of pneumonia episodes worldwide among children under five. Three quarters of all pneumonia episodes worldwide among children under five occur in just 15 countries.14
FIGURE 4 15 COUNTRIES ACCOUNT FOR THREE QUARTERS OF CHILDHOOD PNEUMONIA CASES WORLDWIDE
India 44 million 18 million 7 million 7 million 6 million 6 million 4 million 4 million 3 million 3 million 2 million 2 million 2 million 2 million 2 million 113 million
PNEUMONIA:
China Nigeria Pakistan Bangladesh Indonesia Brazil Ethiopia Congo, Democratic Republic of the Philippines Afghanistan Egypt Mexico
UNICEF/HQ05-0368/Ben Parker
WHO SUFFERS, WHO DIES?
Sudan Viet Nam Total
NOTE: Country-level estimates do not add up to the total due to rounding.
10
FIGURE 5 INCIDENCE OF PNEUMONIA CASES AND PNEUMONIA DEATHS AMONG CHILDREN UNDER FIVE, BY UNICEF REGION, 2004
UNICEF Regions Number of children under five years of age (in thousands) 169,300 117,300 43,400 146,400 56,500 26,400 533,000 54,200 613,600 Number of childhood pneumonia deaths (in thousands) 702 1,022 82 158 50 29 2,039 1 2,044 Incidence of pneumonia cases (episodes per child per year) 0.36 0.30 0.26 0.24 0.22 0.09 0.29 0.03 0.26 Total number of pneumonia episodes (in thousands) 61,300 35,200 11,300 34,500 12,200 2,400 154,500 1,600 158,500
South Asia Sub-Saharan Africa Middle East and North Africa East Asia and Pacific Latin America and Caribbean CEE/CIS Developing countries Industrialized countries World
NOTE: Regional estimates in columns 2, 3 and 5 do not add up to the world total due to rounding.
FIGURE 6 INCIDENCE OF PNEUMONIA IS HIGHEST IN SOUTH ASIA AND SUB-SAHARAN AFRICA

Episodes per child per year, by regions, 2004
HOW TO READ THIS CHART: On average, a child in the developing world will experience 0.29 episodes of pneumonia each year.
Based on data from 134 countries, by UNICEF region, 2004.
11
FIGURE 7 ESTIMATED INCIDENCE OF CHILDHOOD PNEUMONIA WORLDWIDE, 2004
Episodes per child per year 0.199 or less 0.200 - 0.249 0.250 - 0.299 0.300 or more No data availabale
Based on data from 134 countries, 2004. This map does not reflect a position by UNICEF or WHO on the legal status of any country or territory or the delimitation of any frontiers. Dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties.
12
13
LEVELS AND TRENDS IN KNOWLEDGE AND TREATMENT

UNICEF/ HQ05-1586/Giacomo Pirozzi
Because pneumonia kills more children than any other illness, any effort to improve overall child survival must make the reduction of pneumonias death toll a priority. And preventing children from developing pneumonia in the first place is critical to reducing its death toll. Prevention efforts include many wellknown child survival interventions, such as expanding vaccine coverage, promoting adequate nutrition and reducing indoor air pollution (see Box 7 , page 26 ). But once a child develops pneumonia, a caregiver must recognize the symptoms and seek appropriate care immediately. Since a large proportion of severe pneumonia cases in children of the developing world is caused by bacterial pathogens, prompt treatment with a full course of effective antibiotics is key to reducing pneumonia deaths. This approach is proven, affordable and relatively straightforward to implement.15
14
1 2 3
RECOGNIZE a child is sick
SEEK appropriate care
UNICEF/HQ99-0634/Giacomo Pirozzi
TREAT appropriately with antibiotics
Three essential steps are needed to reduce deaths among children under five with pneumonia: 1. Recognize a child is sick 2. Seek appropriate care 3. Treat appropriately with antibiotics Current levels of coverage in the developing world for each of these essential steps are assessed in the sections below, based on data maintained in the UNICEF global databases. Most information in these databases is derived from the UNICEF-supported Multiple Indicator Cluster Surveys (MICS) and the USAID-supported Demographic and Health Surveys (DHS). Additional information from a range of other national-level household surveys is also included (see www.childinfo.org for more information).
15
RECOGNITION OF PNEUMONIAS DANGER SIGNS

Recognizing the symptoms of pneumonia is the first step in reducing deaths among children under five. Caregivers play a critical role in recognizing pneumonias symptoms and immediately seeking appropriate care for their sick children. Indeed, it is critical that caregivers understand the importance of this disease and the risk it poses to their childrens health. Yet, even though pneumonia is the leading killer of children in the developing world, only 1 of every 5 caregivers knows the two tell-tale symptoms of pneumonia: fast breathing and difficult breathing. MICS provide information on caregivers knowledge of pneumonias symptoms, and results from 33 surveys show that these common symptoms of pneumonia are not widely recognized.
FIGURE 8 FEW CAREGIVERS RECOGNIZE THE TWO KEY DANGER SIGNS OF PNEUMONIA
% caregivers who know that difficult or fast breathing is a sign to seek care immediately
Data from 33 MICS, 1999-2001 (see statistical tables 3 and 4).
CARE-SEEKING BEHAVIOUR
The second step is for caregivers to seek appropriate medical care for a child with suspected pneumonia. Appropriate care, as defined by WHO and UNICEF , includes providers that can correctly diagnose and treat pneumonia, such as hospitals, health centres, dispensaries, community health workers, maternal and child health clinics, outreach clinics, and physicians private offices. MICS and DHS provide information on the extent to which caregivers seek an appropriate provider for their children with suspected pneumonia. The surveys permit assessment of disparities in such careseeking behaviour. Only about half (54 per cent) of children under five in the developing world were taken to an appropriate provider. Sub-Saharan Africa has the lowest levels of care-seeking for pneumonia (41 per cent), while the Middle East and North Africa (66 per cent) and East Asia and Pacific, excluding China, (62 per cent) have the highest rates.
16
FIGURE 9 ONLY HALF OF CHILDREN WITH PNEUMONIA TAKEN TO AN APPROPRIATE PROVIDER

% under-fives with pneumonia taken to an appropriate health care provider, by UNICEF region, 1998-2004
See statistical table 1.
UNICEF/HQ00-0917/Roger LeMoyne
Data for a subset of 67 countries from MICS and DHS indicate that caregivers take boys and girls to appropriate medical care almost equally. Perhaps not surprisingly, children in urban areas and those whose mothers have more education are more likely to be taken to an appropriate provider. Also, compared to poor children, children from richer families are around 30 per cent more likely to be taken for appropriate medical care.
17
FIGURE 10 WHO LACKS APPROPRIATE CARE? DISPARITIES IN SEEKING CARE FOR PNEUMONIA
Some children are less likely than others to be taken to an appropriate health care provider for pneumonia. While boys and girls are taken at similar rates, rural children lack appropriate care compared to their urban counterparts. The same is true for poor children compared to rich ones and for children with poorly educated mothers compared to those with better-educated caregivers.
BOYS AND GIRLS SIMILARLY TAKEN TO APPROPRIATE CARE

% under-fives with pneumonia taken to an appropriate health care provider
RURAL CHILDREN MORE OFTEN LACK APPROPRIATE PROVIDER

CHILDREN OF POORLY EDUCATED MOTHERS MORE OFTEN LACK APPROPRIATE CARE

POORER CHILDREN MORE OFTEN LACK APPROPRIATE CARE

Data from 67 DHS and MICS, 1996-2003, except wealth index from 32 MICS, 1999-2003 (see statistical table 2).
18
Trends in care-seeking behaviour

Trend analysis in care-seeking behaviour is in great part limited by the relative lack of data from the early to mid 1990s. However, data from 38 countries, representing more than 60 per cent of the developing worlds population (excluding China), are available to assess trends in care-seeking behaviour for pneumonia over time. These data indicate that there was little change in the rates at which children with pneumonia were taken to an appropriate health care provider between 1994 and 2001. Encouraging signs do emerge from some countries with very low levels of appropriate care. For example, the proportion of children taken to an appropriate provider in Burkina Faso roughly doubled (from 19 per cent to 36 per cent) between 1993 and 2003, according to DHS figures for those two years. Yet 2 out of 3 children sick with pneumonia in that country are still not receiving appropriate care. The lack of any significant progress over the past 10 years across the developing world underscores the urgent need to act now to ensure that children with pneumonia receive appropriate medical care.
UNICEF/ HQ98-0488/Alejandro Balaguer
UNICEF/ HQ04-0264/Christine Nesbitt
19
ANTIBIOTIC TREATMENT FOR PNEUMONIA

Despite the essential role of antibiotics in reducing child deaths from pneumonia, information about antibiotic use is limited. Results from limited data suggest that only 19 per cent of children with pneumonia received an antibiotic in the early 1990s.* In several countries, the proportion of children receiving treatment with antibiotics was less than 10 per cent, leaving 9 of every 10 children to fight the infection unassisted. It is encouraging to note that some countries have increased their levels significantly in a short period of time. In particular, Egypt has increased antibiotic coverage from 25 per cent to 75 per cent in just eight years (1992-2000), while Colombia raised its coverage from 5 per cent to 30 per cent in only four years (1986-1990). Data from this limited number of countries also suggest that antibiotic use was somewhat higher among children with pneumonia in urban areas (24 per cent) compared to children in rural areas (17 per cent). Similarly, antibiotic use was also higher among children of well-educated mothers (27 per cent) compared to children with mothers having no formal education (15 per cent). Questions on antibiotic use for pneumonia have recently been added to MICS and DHS, and it is expected that a large number of countries will report this information over the next several years. This will allow for a more comprehensive assessment of both the current levels and trends in antibiotic usage.
FIGURE 11 CHILDREN UNDER FIVE WITH PNEUMONIA WHO RECEIVED ANTIBIOTICS

(DATA FROM 27 COUNTRIES, MAINLY FROM THE EARLY 1990s)
Total Urban Rural Male Female No formal education Primary education Secondary education
See statistical table 5.
19% 24% 17% 19% 18% 15% 20% 27%
* Currently, only DHS mainly from the early 1990s are available for a sample of 27 countries, and these surveys are subject to under- and over-reporting as a result of caregivers lack of knowledge regarding drug treatments. They also do not record dosage and timing of treatment. It is likely that antibiotic coverage has increased since these data were collected.
20
BOX 4
ANTIBIOTIC RESISTANCE AND SCALING UP TREATMENT FOR PNEUMONIA
Significantly expanding treatment coverage is essential for reducing pneumonia deaths among children under five in the developing world. However, high levels of antibiotic resistance to first-line treatments, notably cotrimoxazole, have been reported in many parts of the world. A study in Pakistan investigated the relationship between high levels of Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) resistance to cotrimoxazole and the clinical efficacy of using this drug to treat children with pneumonia. This study found that despite high levels of cotrimoxazole resistance, treatment failure rates were uncommon among children with pneumonia. Cotrimoxazole, however, was less effective in children with severe cases of pneumonia than amoxicillin.a,b More research is urgently needed to further investigate this critical relationship. Concern remains that expanded and sustained use of antibiotics to treat children with pneumonia could make managing antibiotic resistance more difficult in the future. And prescribing antibiotics to children with a simple cold or cough not only wastes limited resources but also increases antibiotic resistance. Therefore, it is important that scaling up treatment for pneumonia go handin-hand with rigorous training and oversight of health facility personnel and community health workers to ensure proper diagnosis and treatment of pneumonia in communities. Experience from the Gambia, Honduras, Kenya, Nepal and Pakistan, among other study sites, confirms that this can be done successfully.c, d
UNICEF/HQ05-1718/Niclas UNICEF/HQ05-1718/NiclasRyberg Ryberg
21
Preventing a child from developing pneumonia in the first place is essential for reducing deaths. But this is not enough. Children with signs of pneumonia need to be treated promptly with effective antibiotics. The following key actions are needed to reduce pneumonia deaths among children:
ENSURE ALL CAREGIVERS KNOW THE DANGER SIGNS OF PNEUMONIA IN CHILDREN: COUGH AND FAST OR DIFFICULT BREATHING.
Caregivers will need to seek appropriate medical care immediately for children with signs of pneumonia. When only 1 in every 5 caregivers knows pneumonias danger signs, educating caregivers needs to be a top priority. Moreover, given caregivers essential role in home-based treatment, education programmes need to ensure that caregivers broadly understand the importance of the disease and its treatment regimen, and are convinced of treatment efficacy.
KEY ACTIONS
NEEDED TO REDUCE PNEUMONIA DEATHS
ENSURE ALL CHILDREN WITH SIGNS OF PNEUMONIA ARE PROPERLY DIAGNOSED BY TRAINED HEALTH PERSONNEL.
Children with suspected pneumonia in the developing world are diagnosed based on their clinical symptoms, given that radiography and laboratory facilities are largely unavailable in resource-poor settings. Guidelines have been developed for diagnosing pneumonia in children that are of value in distinguishing most pneumonia cases from other respiratory illnesses ( see Box 5, page 24 ).
22
Health personnel, including community health workers, need to be trained to diagnose pneumonia in children under five and given respiratory rate timers to assist this diagnosis. More research is also needed to develop simple diagnostic tests that can be used in community settings to better identify those children with pneumonia who need antibiotics.
ENSURE ALL CHILDREN DIAGNOSED WITH PNEUMONIA ARE TREATED PROMPTLY WITH EFFECTIVE ANTIBIOTICS.
Health personnel, including community health workers, need to be rigorously trained to treat children with pneumonia and refer severe cases to health facilities. Inappropriate antibiotic use, including prescribing antibiotics to children with simple colds or coughs, will not only waste resources, it will also increase antibiotic resistance. Again, guidelines have been developed for diagnosing and treating children with pneumonia in community settings (see Box 5, page 24 ), and numerous countries in the developing world have implemented these guidelines successfully (see Box 6, page 25 ). Moreover, an adequate supply of antibiotics to treat pneumonia needs to be made available to all health facilities and community health workers. In some cases, governments may need to explicitly authorize trained community health workers to prescribe antibiotics for children with pneumonia.
MONITOR REGULARLY THE CLINICAL EFFICACY OF PNEUMONIA TREATMENT TO REVISE NATIONAL TREATMENT POLICIES, AS NECESSARY, BASED ON ANTIMICROBIAL RESISTANCE INFORMATION, CLINICAL OUTCOMES AND OTHER DATA.
UNICEF/HQ05-0441/Boris Heger
23
BOX 5
HOW TO DIAGNOSE AND TREAT PNEUMONIA IN COMMUNITY SETTINGS
Once caregivers have recognized the danger signs of pneumonia (cough and fast or difficult breathing) and taken their children to appropriate medical care, health personnel including trained community health workers should then diagnose and treat pneumonia in children according to the following Integrated Management of Childhood Illness (IMCI) guidelines: a, b Diagnosis: Children aged 2 months to 5 years are diagnosed with pneumonia if they exhibit a cough and fast or difficult breathing. Thresholds for fast breathing depend on the childs age (see What is fast breathing?, below). Severe pneumonia in children is diagnosed if they exhibit lower chest wall indrawing (when the childs chest moves in or retracts during inhalation) or stridor (a harsh noise made during inhalation). Respiratory rate timers should be available to help health personnel count breathing rates. Treatment: Children aged 2 months to 5 years with severe pneumonia should be referred to the nearest health facility immediately. Those diagnosed with pneumonia may be treated at home with a full course of effective antibiotics.c Infants less than 2 months old with signs of pneumonia should be referred promptly to the nearest health facility because they are at high risk of suffering severe illness or death.
SIGNS Fast breathing (see below) Lower chest wall indrawing Stridor in calm child Fast breathing (see below)
CLASSIFY AS Severe pneumonia
TREATMENT Refer urgently to hospital for injectable antibiotics and oxygen if needed Give first dose of appropriate antibiotic Prescribe appropriate antibiotic Advise mother on other supportive measures and when to return for a follow-up visit
UNICEF/ HQ05-1580/Giacomo Pirozzi
Non-severe pneumonia
No fast breathing
Other respiratory illness Advise mother on other supportive measures and when to return if symptoms persist or get worse
WHAT IS FAST BREATHING? If the child is... 2 months to 12 months old 12 months to 5 years old The child has fast breathing if you count 50 breaths or more per minute 40 breaths or more per minute
24
BOX 6
COMMUNITY-BASED CASE MANAGEMENT OF PNEUMONIA SIGNIFICANTLY REDUCES CHILD MORTALITY: EVIDENCE FROM NINE STUDIES
A meta-analysisa of results from nine studies that investigated the impact of community-based case management of pneumonia on child mortality was recently completed. In these studies, children with pneumonia were diagnosed and treated according to the guidelines described in Box 5, page 24. Across these nine trials, total mortality was reduced by 27 per cent, 20 per cent and 24 per cent among neonates, infants and chidren 0-4 years, respectively. Mortality from pneumonia among these same three groups was found to be reduced by 42 per cent, 36 per cent and 36 per cent. The larger-than-expected effect of intervening to prevent pneumonia deaths suggests the important indirect role of pneumonia as a cause of death. The authors conclude that community-based interventions to diagnose and treat pneumonia have a significant impact on under-five mortality and should urgently be incorporated into primary health care in developing countries. An important finding of the analysis was that the communitybased case management approach works even in the most difficult and deprived settings and among children with multiple risk factors. Indeed, its impact will be greatest in those areas with poorest access to health care. Organized training of community health workers in such areas remains one of the great challenges still to be tackled. More research is also urgently needed to determine how effectively the community-based case management approach can be implemented at a national scale while maintaining adequate control over antibiotic prescribing practice.
25
BOX 7
PREVENTING PNEUMONIA IS KEY
Reducing pneumonia deaths also requires implementing effective prevention measures so that children are healthier and less likely to develop pneumonia in the first place. The prevention measures listed below all show at least some evidence of reducing pneumonia mortality among under-fives.a Some research has also suggested that hand washing and lowering indoor air pollution play a role in reducing pneumonia deaths among children in the developing world.b, c For HIV-infected children, preventing pneumonia (PCP) through cotrimoxazole prophylaxis is essential (see Box 3, page 8 ).d
IMMUNIZATION
Immunizations help reduce childhood deaths from pneumonia in two ways. First, vaccinations help prevent children from developing infections that directly cause pneumonia, such as Haemophilus influenzae type b (Hib). Second, immunizations may prevent infections that can lead to pneumonia as a complication (e.g., measles and pertussis). Three vaccines have the potential to significantly reduce child deaths from pneumonia. These vaccines include the measles, Hib and pneumococcal conjugate vaccines. Their ability to reduce pneumonia deaths is detailed in Box 8, page 27.
ADEQUATE NUTRITION
Undernourished children are at a substantially higher risk of suffering childhood death or disability. It has been estimated that child undernutrition contributes to more than half of all child deaths in developing countries, and that undernutrition in children aged 0-4 years contributes to more than 1 million pneumonia deaths each year.e Undernutrition may place children at an increased risk of developing pneumonia in two ways. First, malnutrition weakens a childs overall immune system, as an adequate amount of protein and energy is needed for proper immune system functioning. Second, undernourished children have weakened respiratory muscles, which inhibits them from adequately clearing secretions found in their respiratory tract.f, g
EXCLUSIVE BREASTFEEDING
It is widely recognized that children who are exclusively breastfed develop fewer infections and have less severe illnesses than those who are not. Breast milk contains the nutrients, antioxidants, hormones and antibodies needed by the child to survive and develop, and specifically for a childs immune system to function properly. Yet only about one third of infants in the developing world are exclusively breastfed for the first six months of life.h Infants under six months old who are not breastfed are at five times the risk of dying from pneumonia as infants who are exclusively breastfed for the first six months of life. Furthermore, infants 6 - 11 months old who are not breastfed are also at an increased risk of dying from pneumonia compared to those who are breastfed. i
ZINC
Children who lack sufficient amounts of specific micronutrients, particularly zinc, face additional risks of developing and dying from pneumonia. A growing body of research highlights the importance of zinc to child survival and to specifically reducing deaths from pneumonia. j, k, l Zinc intake helps reduce the incidence of pneumonia and the severity of the disease. Specifically, research has shown that zinc intake during the acute phase of severe pneumonia decreased the duration and severity of pneumonia and reduced treatment failure rates when compared with a placebo intervention.m Improving the zinc status of children is currently being considered by public health and nutrition experts.
26
BOX 8
VACCINES HOLD PROMISE OF SAVING MILLIONS OF CHILDREN FROM DYING OF PNEUMONIA
Three vaccines have the potential to save millions of childrens lives by reducing deaths from pneumonia. These vaccines work to reduce the incidence of pneumonia caused by the bacterial pathogens Streptococcus pneumoniae (pneumococcal conjugate vaccine) and Haemophilus influenzae type b (Hib vaccine), as well as pneumonia caused by serious complications from measles (measles vaccine).
MEASLES VACCINE
Measles is an acute viral infection that often causes only a self-limiting illness in children. But complications that can lead to disability or death are relatively common, especially in children who are undernourished or have compromised immune systems. Pneumonia is a serious complication of measles, and the most common cause of death associated with measles worldwide. Thus, reducing the incidence of measles in young children through vaccination would also help to reduce deaths from pneumonia.a A safe and effective measles vaccine has been available for use in developing countries for the past 40 years, and the coverage rate for the measles vaccine was estimated at 76 per cent worldwide in 2004.b Yet despite much progress in increasing vaccine coverage, measles still infects about 30 million to 40 million children each year.c
HIB VACCINE
Haemophilus influenzae type b (Hib) is an important cause of pneumonia and meningitis among children in developing countries. It has been estimated that Hib causes 2 to 3 million cases of severe disease every year.d Hib vaccine has been available for more than a decade, but its high cost and limited information on Hib disease in some areas have posed obstacles to its introduction in developing countries. While in developed countries 92 per cent of the population was vaccinated against Hib in 2003, vaccine coverage was 42 per cent in the developing world and just 8 per cent in the least developed countries during that time.e Expanding coverage to more children in the developing world is urgently needed. An advisory group established by the World Health Organization recently recommended that Hib vaccine be made available to all developing countries except where evidence indicates a low burden of disease or where overwhelming impediments to implementation exist.f
PNEUMOCOCCAL CONJUGATE VACCINE

Streptococcus pneumoniae is the most common cause of severe pneumonia among children in the developing world. Vaccines to protect against this infection have been available for adults and children over 2 years of age for years, but only recently has a new vaccine been developed that is suitable for infants and toddlers, called the pneumococcal conjugate vaccine (PCV). In 2000, the United States approved this vaccine for use in routine immunizations of all infants, and many other countries have also implemented this vaccine with success.
The vaccine used in the United States is seven-valent (PCV7), meaning that it includes the seven most common pneumococcal serotypes found in industrialized countries. Manufacturers are also developing newer vaccines that work against 9-, 11- or 13-valent pneumococcal serotypes, which will provide increased coverage of the serotypes most commonly found in developing countries. These vaccines may become available as early as 2008. Recent results from trials of 17,000 children in the Gambia showed that children immunized with the 9-valent vaccine had 37 per cent fewer cases of pneumonia (as confirmed by chest X-rays), 15 per cent fewer hospitalizations and a 16 per cent reduction in overall mortality. Indeed, the trial showed this vaccine to be highly effective in reducing child deaths from pneumonia.g
27
More than 1 million lives could be saved if both prevention and treatment interventions for pneumonia were implemented universally. Around 600,000 childrens lives could be saved each year through universal treatment with antibiotics alone, costing around $600 million.16 It is important to note that this cost estimate refers only to treatment costs and does not include investments such as prevention efforts or funding for pneumonia research. However, the cost does include more than simply the purchase price of antibiotics, which is very little in most countries (an appropriate course of antibiotics for treating pneumonia costs on average about $0.27). Also included in the estimate are the costs of scaling up treatment coverage to universal levels, which include training and supervising staff and funding hospital stays for those children with severe pneumonia. These investments are not only critical for expanding treatment coverage with antibiotics but are also necessary for strengthening the broader health system. This estimated total includes costs for Mexico and Brazil, which are disproportionately high because service delivery and hospitalization are much more expensive in those two countries. At the same time, around 85 per cent of pneumonia deaths among children under five occur in sub-Saharan Africa and South Asia, where treatment costs are much lower. In fact, it is estimated that expanding treatment coverage to universal levels in those two regions alone would cost only $200 million a year, which means that one third of the entire $600 million would address 85 per cent of the problem.
THE COST OF REDUCING PNEUMONIA DEATHS
28
UNICEF/ HQ05-0336/Josh Estey
Pneumonia is the leading killer of children under five, yet it has become a forgotten pandemic. Few headlines report the impact pneumonia has on childrens lives. Yet the toll pneumonia exacts on children of the developing world would surprise, or even shock, most readers. A few major public health scourges, like malaria and AIDS, have rightly received increased attention in recent years. Yet the increased funding that has accompanied that attention is still insufficient to reduce their heavy burdens. Incredibly, pneumonia which kills more children under five than AIDS, malaria and measles combined has received far less attention and funding than any of them. Each year, more than 2 million children under five die of pneumonia in the developing world, compared to an estimated 800,000 children who die from malaria and around 300,000 children under five who die from AIDS (out of about 3 million total AIDS deaths). Limited information exists on donor spending directed specifically towards reducing pneumonia deaths. Most donor spending on pneumonia is channelled through broader child health initiatives, such as integrated child survival intervention programmes and immunization efforts. These activities are critical to reducing child deaths, including those from pneumonia, and must be urgently strengthened and expanded.
PNEUMONIA: A FORGOTTEN
PANDEMIC
UNICEF/ HQ06-0042/Indrias Getachew
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APPENDIX
DATA USED IN THIS REPORT
The data used in this report were derived from a range of sources. Cause-specific mortality estimates and the incidence of pneumonia were based on the work of the Child Health Epidemiological Reference Group (CHERG), which is coordinated by the World Health Organization (Department of Child and Adolescent Health and Development), and supported by the Evidence and Information for Policy Cluster of WHO, with financial support from the Bill and Melinda Gates Foundation. Careseeking behaviour data were derived from household surveys compiled by UNICEF headquarters as part of its ongoing monitoring work on child survival. In addition, a more detailed analysis was conducted on DHS and MICS to assess knowledge of danger signs, antibiotic use for pneumonia and care-seeking behaviour by background characteristics. More specific details on these data sources are summarized below. based on 97 national-level household surveys conducted in the developing world. The majority of data is derived from the UNICEF-supported Multiple Indicator Cluster Surveys (MICS) and the USAID-supported Demographic and Health Surveys (DHS). However, information from a range of other national-level household surveys, such as the Gulf Child Health Surveys, is included. The latest available estimates from this database are published annually in UNICEFs The State of the Worlds Children report and are available at: www.childinfo.org. Data on care-seeking behaviour are derived from the surveys included in the UNICEF global database and are based on questions about whether and where advice or treatment were sought outside the home for children with symptoms of pneumonia. Estimates were tabulated for the percentage of children with suspected pneumonia who were taken to an appropriate provider. Appropriate providers for the treatment of pneumonia include hospitals, health centres, dispensaries, village health workers, maternal and child health clinics, mobile or outreach clinics, and private physicians. Traditional healers, pharmacies/drug sellers and relatives/friends are not included. Further analysis was conducted by UNICEF on a subset of 67 MICS and DHS to assess disparities in care-seeking behaviour by residence, gender and maternal education. Disparities by wealth quintile were based on 32 MICS only.
CAUSE-SPECIFIC MORTALITY
As mentioned above, data on pneumonia-specific mortality were based on the work of the CHERG, which was established in 2001 by WHO to estimate the distribution of under-five deaths by cause. The CHERG has used various methods, including single-cause and multi-cause proportionate mortality models. It should be noted that the distribution of under-five deaths by cause refers to the primary cause of death. The most recent update of the cause-specific mortality figures was done for the period 2000-2003. The resulting proportionate mortality estimates were applied in this report to the 2004 envelope of total under-five deaths in the developing world (10.5 million deaths in 2004) to arrive at the number of under-five deaths due to pneumonia that occurred in 2004.17 Further details on the specific methods used by the CHERG to estimate cause-specific mortality are available at http://www.who.int/child-adolescent-health/.
KNOWLEDGE OF PNEUMONIAS DANGER SIGNS

Data on mothers or caregivers knowledge of danger signs of pneumonia, including fast breathing or difficult breathing, were analysed from 33 MICS. This information was based on the question, What types of symptoms would cause you to take your child to a health facility right away? Respondents could provide multiple responses but were not prompted about specific symptoms. It is, of course, possible that some responses were simply omitted by the respondent because the symptom did not immediately come to mind. Results on knowledge of danger signs may therefore be somewhat underreported.
INCIDENCE OF PNEUMONIA
This report includes updated estimates for the global and regional incidences of pneumonia. These incidence estimates are based on prevalence data for childrens exposure to the major pneumonia risk factors in each country relative to the global exposure. These risk factors include: underweight prevalence (weight for age less than two standard deviations from the median value of the standard reference population), low birthweight (less than 2,500 grams at birth), lack of exclusive breastfeeding for the first six months of life, measles immunization rates and crowding (five or more persons per household). All risk factors except crowding were derived from the UNICEF global databases. Country-level estimates of pneumonia incidence were then aggregated to derive estimates for UNICEF regions in 2004.18
ANTIBIOTIC COVERAGE
Estimates on the use of antibiotics for treating pneumonia at a national level are not readily available. A few DHS, mainly conducted in the early 1990s, did include questions on antibiotic use, but results were generally not published in the survey reports. For the purpose of this analysis, all available data on antibiotic use from the DHS were analysed, including 27 surveys mainly from the early 1990s. Overall antibiotic coverage was calculated for children with pneumonia in the two weeks prior to the survey, as well as disparities by residence, gender and maternal education. It should be noted that these data do not specify the type of antibiotic used nor whether proper dosing was applied. Responses to survey questions on antibiotic use will be limited by mothers/caregivers knowledge about the drugs given to treat the disease. It is also expected that antibiotic coverage has increased since these data were collected.
CARE-SEEKING FOR PNEUMONIA

UNICEF headquarters maintains a global database on the frequency of care-seeking for suspected pneumonia,
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REFERENCES
1. Jones, G., et al., How Many Child Deaths Can We Prevent This Year?, The Lancet, vol. 362, 2003, pp. 65-71; Bryce, J., et al., Can the World Afford to Save the Lives of 6 Million Children Each Year?, The Lancet, vol. 365, 2005, pp. 2193-2200. 2. World Health Organization, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, World Health Organization, Geneva, 1992. 3. National Institutes of Health, Pneumococcal Pneumonia, <http://www.niaid.nih.gov/factsheets/pneumonia.htm> [accessed November 2005]; World Health Organization and UNICEF , Integrated Management of Childhood Illness Handbook, World Health Organization, Geneva, 2005. 4. World Health Organization and UNICEF , Integrated Management of Childhood Illness Handbook, World Health Organization, Geneva, 2005; World Health Organization, Technical Basis for the WHO Recommendations on the Management of Pneumonia in Children at First-Level Health Facilities, WHO/ARI/91.20, Programme for the Control of Acute Respiratory Infections, World Health Organization, Geneva, 1991. 5. National Institutes of Health, Pneumococcal Pneumonia, <http://www.niaid.nih.gov/factsheets/pneumonia.htm> [accessed November 2005]. 6. Berman, S., Epidemiology of Acute Respiratory Infections in Children of Developing Countries, Reviews of Infectious Diseases, vol. 13, no. 6, 1991, pp. S454-462; Smith, K.R., J.M. Sarnet, I. Romieu and N. Bruce, Indoor Air Pollution in Developing Countries and Acute Lower Respiratory Infections in Children, Thorax, vol. 55, 2000, pp. 518-532; Fishman, S.M., et al., Childhood and maternal underweight in Ezzati, M., A. Lopez, A. Rodgers and C. Murray, eds., Comparative Quantification of Health Risks: The Global and Regional Burden of Disease Attributable to Selected Major Risk Factors, World Health Organization, Geneva, 2004; Black, R.E., Zinc Deficiency, Infectious Disease and Mortality in the Developing World, Journal of Nutrition, vol. 133, 2003, pp. 1485S-1489S; World Health Organization, WHO Expert Consultation on Cotrimoxazole Prophylaxis in HIV Infection, draft meeting report, Geneva, 10-12 May 2005. 7 . Jones, G., et al., How Many Child Deaths Can We Prevent This Year?, The Lancet, vol. 362, 2003, pp. 65-71. 8. World Health Organization, WHO Expert Consultation on Cotrimoxazole Prophylaxis in HIV Infection, draft meeting report, Geneva, 10-12 May 2005. 9. Luby, S.P ., et al., Effect of Handwashing on Child Health: A Randomised Controlled Trial, The Lancet, vol. 366, 2005, pp. 225-233. 10. World Health Organization and UNICEF , Joint Statement on Management of Pneumonia in the Community, New York, 2004, available at <http://www.unicef.org/publications/ index_21431.html> [accessed February 2006]. 11. World Health Organization and UNICEF , Joint Statement on Management of Pneumonia in the Community, New York, 2004, available at <http://www.unicef.org/publications/ index_21431.html> [accessed February 2006]; Sazawal, S., and R.E. Black, for the Pneumonia Case Management Trials Group, Effect of Pneumonia Case Management on Mortality in Neonates, Infants, and Preschool Children: A Meta-Analysis of Community-Based Trials, The Lancet Infectious Diseases, vol. 3, 2003, pp. 547-556. 12. World Health Organization, Technical Basis for the WHO Recommendations on the Management of Pneumonia in Children at First-Level Health Facilities, 1991, op. cit.; World Health Organization and UNICEF , Integrated Management of Childhood Illness Handbook, 2005, op. cit. 13. Rudan, Igor, Lana Tomaskovic, Cynthia Boschi-Pinto and Harry Campbell, on behalf of the Child Health Epidemiology Reference Group, Global estimates of the incidence of clinical pneumonia among children under five years of age, Bulletin of the World Health Organization, vol. 82, no. 12, 2004, pp. 895-903. 14. Personal communication from I. Rudan, Associate Professor, University of Edinburgh, November 2005, based on Rudan, I., C. Boschi-Pinto, T. Wardlaw, E. White Johansson and H. Campbell, The Global Distribution of Clinical Episodes of Pneumonia in Children Under Five Years of Age (submitted for publication). 15 World Health Organization and UNICEF , Joint Statement on Management of Pneumonia in the Community, New York, 2004, available at <http://www.unicef.org/publications /index_21431.html> [accessed February 2006]; Sazawal, S., and R.E. Black, for the Pneumonia Case Management Trials Group, Effect of Pneumonia Case Management on Mortality in Neonates, Infants, and Preschool Children: A Meta-Analysis of Community-Based Trials, The Lancet Infectious Diseases, vol. 3, 2003, pp. 547-556. 16. Bryce, J., et al., Can the World Afford to Save the Lives of 6 Million Children Each Year?, The Lancet, vol. 365, 2005, pp. 2193-2200; Jones, G., et al., How Many Child Deaths Can We Prevent This Year?, The Lancet, vol. 362, 2003, pp. 65-71. 17 . Bryce, J., C. Boschi-Pinto, K. Shibuya, R.E. Black, and the Child Health Epidemiology Reference Group, WHO Estimates of the Causes of Death in Children, The Lancet, vol. 365, 2005, pp. 1147-1152. 18. Rudan, Igor, Lana Tomaskovic, Cynthia Boschi-Pinto and Harry Campbell, on behalf of the Child Health Epidemiology Reference Group, Global estimates of the incidence of clinical pneumonia among children under five years of age, Bulletin of the World Health Organization, vol. 82, no. 12, 2004, pp. 895-903; Personal communication from I. Rudan, Associate Professor, University of Edinburgh, November 2005, based on Rudan, I., C. Boschi-Pinto, T. Wardlaw, E. White Johansson and H. Campbell, The Global Distribution of Clinical Episodes of Pneumonia in Children Under Five Years of Age (submitted for publication).
31
FIGURES
FIGURES 1 & 2 Cause-specific mortality estimates from: World Health Organization, World Health Report 2005: Make Every Mother and Child Count, World Health Organization, Geneva, 2005; under-five mortality estimates from: UNICEF , The State of the Worlds Children 2006, UNICEF , New York, 2005; Bryce, J., C. Boschi-Pinto, K. Shibuya and R.E. Black, on behalf of the Child Epidemiology Reference Group, WHO Estimates of the Causes of Death in Children, The Lancet, 2005, vol. 365, pp. 1147-1152; Lawn, J.E., K. Wilczynska-Ketende and S. Cousens, Estimates of Causes of 4 Million Neonatal Deaths in the Year 2000, International Journal of Epidemiology, vol. 35, no. 3, 2006, pp. 706-718; World Health Organization, World Health Statistics 2006, World Health Organization, Geneva, 2006. FIGURE 3 Data on the pathogen-specific causes of pneumonia are limited, and available data are often difficult to interpret. The rough estimates presented in this table draw largely on the following sources, as well as on communications with various pneumonia experts. World Health Organization, Technical Basis for the WHO Recommendations on the Management of Pneumonia in Children at First-Level Health Facilities, 1991, op. cit. Mulholland, K., Magnitude of the Problem of Childhood Pneumonia, The Lancet, vol. 354, 1999, pp. 590-592; de Andrade, A.L. and C.M. Martelli, Globalization of Hib Vaccination How Far Are We?, The Lancet vol. 365, 2005, pp. 5-7; Cutts, F .T., et al., Efficacy of Nine-valent Pneumococcal Conjugate Vaccine against Pneumonia and Invasive Pneumococcal Disease in The Gambia: Randomised, Doubleblind, Placebo-controlled Trial, The Lancet, vol. 365, 2005, pp. 1139-1146; World Health Organization, Review panel on Haemophilus influenzae type-b (Hib) disease burden in Bangladesh, Indonesia and other Asian countries, Bangkok, 2829 January 2004, Weekly epidemiological record, vol. 79, no. 18, 2004, pp. 173-175; Gessner, B.D., et al., Incidences of VaccinePreventable Haemophilus Influenzae type-b Pneumonia and Meningitis in Indonesian Children: Hamlet Randomised Vaccine-Probe Trial, The Lancet, vol. 365, 2005, pp. 43-52; Mulholland, K., et al., Randomised trial of Haemophilus Influenzae type-b Tetanus Protein Conjugate for Prevention of Pneumonia and Meningitis in Gambian infants, The Lancet, vol. 349, 1997 , pp. 1191-1197; Berkley, J.A., et al., Bacteremia among Children Admitted to a Rural Hospital in Kenya, The New England Journal of Medicine, vol. 352, 2005, pp. 39-47 . FIGURE 5 Under-five population from: UNICEF , The State of the Worlds Children 2006, UNICEF , New York, 2005; Global estimates of pneumonia incidence are from: Rudan, Igor, Lana Tomaskovic, Cynthia Boschi-Pinto and Harry Campbell, on behalf of the Child Health Epidemiology Reference Group, Global estimates of the incidence of clinical pneumonia among children under five years of age, Bulletin of the World Health Organization, vol. 82, no. 12, 2004, pp. 895-903; Regional- and national-level pneumonia incidence estimates from: Personal communica-
tion from I. Rudan, Associate Professor, University of Edinburgh, November 2005, based on Rudan, I., C. BoschiPinto, T. Wardlaw, E. White Johansson and H. Campbell, The Global Distribution of Clinical Episodes of Pneumonia in Children Under Five Years of Age (submitted for publication); Estimates of childhood pneumonia deaths are based on the work of the CHERG (see Appendix) and appear in World Health Organization, World Health Statistics 2006, World Health Organization, Geneva, 2006. FIGURES 4, 6 & 7 Personal communication from I. Rudan, Associate Professor, University of Edinburgh, November 2005, based on Rudan, I., C. Boschi-Pinto, T. Wardlaw, E. White Johansson and H. Campbell, The Global Distribution of Clinical Episodes of Pneumonia in Children Under Five Years of Age (submitted for publication). FIGURE 8 Based on data appearing in statistical tables 3 and 4. FIGURE 9 , UNICEF , The State of the Worlds Children 2006, UNICEF New York, 2005. Based on the latest estimates available between the period 1998 and 2004, except data from Brazil, which is for 1996. Also see statistical table 1. FIGURE 10 Based on data appearing in statistical table 2. FIGURE 11 Based on data appearing in statistical table 5.
BOXES
BOX 2 a. World Health Organization, Technical Basis for the WHO Recommendations on the Management of Pneumonia in Children at First-Level Health Facilities, 1991, op. cit. b. World Health Organization and UNICEF , Integrated Management of Childhood Illness Handbook, 2005, op. cit. c. World Health Organization, Technical Basis for the WHO Recommendations on the Management of Pneumonia in Children at First-Level Health Facilities, 1991, op. cit. BOX 3 a. World Health Organization, WHO Expert Consultation on Cotrimoxazole Prophylaxis in HIV Infection, 2005, op. cit. b. UNICEF estimate based on cause-specific mortality estimates developed by the CHERG (see Appendix) and an estimate of AIDS deaths due to pneumonia in sub-Saharan Africa (31 per cent) from Chintu, C. et al, Co-trimoxazole as Prophylaxis Against Opportunistic Infections in HIV-infected Zambian Children (CHAP): A Double-Blind Randomised Placebo-Controlled Trial, The Lancet, vol. 364, 2004, pp. 1865-1871.
32
c. World Health Organization, WHO Expert Consultation on Cotrimoxazole Prophylaxis in HIV Infection, 2005, op. cit. d. Ibid. e. Ibid. BOX 4 a. Straus, W.L., S.A. Qazi, Z. Kundi, N.K. Nomani, B. Schwartz and the Pakistan Co-trimoxazole Study Group, Antimicrobial Resistance and Clinical Effectiveness of Co-trimoxazole Versus Amoxicillin for Pneumonia among Children in Pakistan: Randomised Controlled Trial, The Lancet, vol. 352, 1998, pp. 270-274. b. Rasmussen, Z., et al., Case Management of Childhood Pneumonia in Developing Countries: Recent Relevant Research and Current Initiatives, International Journal of Tuberculosis and Lung Disease, vol. 4, no. 9, 2000, pp. 807-826. c. World Health Organization and UNICEF , Joint Statement on Management of Pneumonia in the Community New York, 2004, available at <http://www.unicef.org/ publications/index_21431.html> [accessed February 2006]. d. Sazawal, S. and R.E. Black, for the Pneumonia Case Management Trials Group, Effect of Pneumonia Case Management on Mortality in Neonates, Infants, and Preschool Children: A Meta-Analysis of CommunityBased Trials, The Lancet Infectious Diseases, vol. 3, 2003, pp. 547-556. BOX 5 a. World Health Organization and UNICEF , Integrated Management of Childhood Illness Handbook, 2005, op. cit. b. World Health Organization, Technical Basis for the WHO Recommendations on the Management of Pneumonia in Children at First-Level Health Facilities, 1991, op. cit. c. World Health Organization and UNICEF, Joint Statement on Management of Pneumonia in the Community New York, 2004, available at <http://www.unicef.org/publications/index_21431.html> [accessed February 2006]. BOX 6 a. Sazawal, S., and R.E. Black, Effect of pneumonia case management on mortality in neonates, infants and preschool children: a meta-analysis of communitybased trials, The Lancet Infectious Diseases, vol. 3, 2003, pp. 547-556. BOX 7 a. Jones, G., et al., 2003, op. cit. b. Luby, S.P ., et al., 2005, op. cit. c. Smith, K.R., J.M. Sarnet, I. Romieu and N. Bruce, Indoor Air Pollution in Developing Countries and Acute Lower Respiratory Infections in Children, Thorax, vol. d. e.
f. g.
h. i.
j.
k.
l. m.
55, 2000, pp. 518-532; Tun, K.M., et al., Indoor Air Pollution: Impact of Intervention on Acute Respiratory Infection (ARI) in Under-Five Children, Regional Health Forum, vol. 9, no. 1, 2005, pp. 30-36. World Health Organization, WHO Expert Consultation on Cotrimoxazole Prophylaxis in HIV Infection, 2005, op. cit. Fishman, S.M., et al., Childhood and maternal underweight in Ezzati, M., A. Lopez, A. Rodgers and C. Murray, eds., Comparative Quantification of Health Risks: The Global and Regional Burden of Disease Attributable to Selected Major Risk Factors, World Health Organization, Geneva, 2004. Ibid. Victora, C., et al., Potential Interventions for the Prevention of Childhood Pneumonia in Developing Countries: Improving Nutrition, American Journal of Clinical Nutrition, vol. 70, 1999, pp. 309-320. UNICEF , The State of the Worlds Children 2006, op. cit. Black, R.E., et al., Where and Why are 10 Million Children Dying Every Year?, The Lancet, vol. 361, 2003, pp. 2226-2234. Brooks, A., et al., Effect of Weekly Zinc Supplements on Incidence of Pneumonia and Diarrhoea in Children Younger than 2 years in an Urban, Low-Income Population in Bangladesh: Randomised Controlled Trial, The Lancet, vol. 366, 2005, pp. 999-1003. Black, R.E., Zinc Deficiency, Infectious Disease and Mortality in the Developing World, Journal of Nutrition, vol. 133, 2003, pp. 1485S-1489S. Bhatnagar, S., et al., Zinc in Child Health and Disease, Indian Journal of Pediatrics, vol. 71, pp. 991-995. Brooks, A., et al., 2005, op. cit.
BOX 8 a. Veirum, J.E., et al., Routine Vaccinations Associated with Divergent Effects on Female and Male Mortality at the Pediatric Ward in Bissau, Guinea-Bissau, Vaccine, vol. 23, 2005, pp. 1197-1204. b. UNICEF , The State of the Worlds Children 2006, op. cit. c. UNICEF , Immunization Plus, <http://www.unicef.org/ immunization/index_measles.html> [accessed November 2005]. d. UNICEF, Immunization: Hib, <http://www.unicef.org/ immunization/23245_hib.html> [accessed November 2005]. e. World Health Organization, Haemophilus influenzae type-b (Hib), <http://www.who.int/mediacentre/factsheets/ fs294/en/index.html> [accessed February 2006]. f. World Health Organization, Weekly Epidemiological Record, January 6, 2006, vol. 81, pp. 1-12, available at <http://www.who.int/immunization/Conclusions_recommendations.pdf> [accessed February 2006].
g. Cutts, F ., et al., Efficacy of Nine-valent Pneumococcal Conjugate Vaccine Against Pneumonia and Invasive Pneumococcal Disease in The Gambia: Randomised, Double-blind, Placebo-controlled Trial, The Lancet, vol. 365, 2005, pp. 1139-1146.
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TABLE 1 KEY PNEUMONIA INDICATORS: MORTALITY, PREVENTION AND TREATMENT

PNEUMONIA DEATHS
Total Total number of number of under-five under-five children deaths (000s) (000s) % of Total number under-five of under-five deaths pneumonia due to deaths pneumonia (000s)a
PREVENTION
% of children who are underweight (0-59 months) moderate severe & severe (1996-2004)* (1996-2004)* 39 14 10 31 10 x 5 3 7 9x 48 6x 6x 23 19 8 4 13 6 38 45 45 18 14 x 24 28 1 8 7 25 14 31 5 17 1 4 1x 18 5x 5 12 9 10 19 40 47 8x 12 1 3 8 4 1 0 1 2 13 1 1 5 3 1 1 2 1 14 13 13 4 2 6 9 1 9 3 9 0 5 0 0 6 0 1 1 1 4 12 16 1 % of infants who are exclusively breastfed (<6 months) (1996-2004)* 6 13 11 30 7 34 x, k 36 24 k 38 54 6 34 19 62 12 21 57 k 17 2 63 51 26 21 4k 24 19 k 35 x, k 5 23 41 10 35 30 24 24 52 55 47 x, k % of one-yearold children immunized against: measles Hib 2004 61 96 81 98 64 97 95 92 93 74 98 89 99 77 98 99 82 95 85 87 64 88 90 99 99 95 78 75 80 64 95 69 35 56 95 84 92 73 65 64 99 88 49 96 99 86 97 96 60 99 79 99 97 93 51 84 96 71 62 2004 95 97 90 95 83 93 98 93 95 96 81 79 96 92 83 83 94 89 90 93 99 58 98 95 71 90 83 27 71
TREATMENT
% of under-fives with pneumonia taken to an appropriate healthcare provider 1998-2004* 28 83 52 58 26 36 20 66 35 52 80 14 46 36 40 37 40 32 22 51 49 36 38 64 70 62 44 16 -
Countries and territories
Under-five mortality rate
2004 Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Congo, Democratic Republic of the Cook Islands Costa Rica Cte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji 257 19 40 7 260 12 18 32 6 5 90 13 11 77 12 11 5 39 152 80 69 15 116 34 9 15 192 190 141 149 6 36 193 200 8 31 21 70 108 205 21 13 194 7 7 5 4 5 126 14 32 26 36 28 204 82 8 166 20
2004 359 1 27 0 195 0 12 1 1 0 12 0 0 288 0 1 1 0 52 5 18 1 5 127 0 1 115 63 60 84 2 1 29 91 2 539 20 2 19 572 0 1 128 0 1 0 0 0 3 0 7 8 68 5 4 14 0 509 0
2004 5,329 256 3,099 3 2,887 8 3,350 164 1,257 387 607 30 65 17,284 16 444 565 34 1,406 289 1,231 194 221 17,946 40 332 2,393 1,270 1,801 2,434 1,705 70 636 1,804 1,246 86,055 4,734 125 727 10,829 2 393 2,751 210 689 49 449 329 120 7 997 1,449 8,795 804 86 733 63 12,861 93
2004 25 11 14 25 2 3 12 1 1 18 5 1 18 0 9 1 7 21 19 17 3 1 13 1 16 23 23 21 22 1 13 19 23 6 13 10 16 14 23 1 4 20 1 4 2 4 1 20 0 13 12 15 13 17 19 2 22 9
2004 89 0 4 48 0 0 0 0 0 2 0 0 51 0 0 0 0 11 1 3 0 0 17 0 0 27 14 12 18 0 0 5 21 0 72 2 0 3 132 0 0 25 0 0 0 0 0 1 0 1 1 10 1 1 3 0 114 0
x x
34
TABLE 1 KEY PNEUMONIA INDICATORS: MORTALITY, PREVENTION AND TREATMENT (CONTINUED)

PNEUMONIA DEATHS
Total Total number of number of under-five under-five children deaths (000s) (000s) % of Total number under-five of under-five deaths pneumonia due to deaths pneumonia (000s)a
PREVENTION
% of children who are underweight (0-59 months) moderate severe & severe (1996-2004)* (1996-2004)* 12 17 3 22 23 21 25 14 17 17 2x 47 28 11 16 4 4 4 20 13 x 23 10 11 40 3 18 26 5x 42 22 11 30 33 32 15 x 8 3 13 2 2 4 0 5 4 7 3 4 0 18 9 2 2 1 0 4 8 3 2 13 0 4 8 1 11 1 7 11 10 2 1 3 0 % of infants who are exclusively breastfed (<6 months) (1996-2004)* 6 26 18 k 53 39 k 51 23 37 11 24 35 37 k 40 44 12 27 36 13 80 x, k 65 12 k 24 23 27 k 15 35 67 44 29 k 10 25 63 x, k 20 21 k 38 x, k 60 k 51 11 k % of one-yearold children immunized against: measles Hib 2004 97 86 55 90 86 92 83 88 74 75 73 80 88 54 92 99 93 56 72 96 90 81 96 84 80 99 99 99 73 56 95 99 97 99 36 99 96 70 42 99 98 91 59 80 95 97 75 87 70 64 98 96 85 96 99 96 96 2004 96 86 90 90 80 88 83 91 89 99 99 89 96 90 77 95 73 98 95 92 35 86 89 99 55 46 98 65 99 -
TREATMENT
% of under-fives with pneumonia taken to an appropriate healthcare provider 1998-2004* 48 75 99 44 64 33 64 78 26 67 61 93 76 39 78 48 49 93 48 36 74 49 70 48 27 22 36 41 78 78 97
2004 Finland 4 France 5 Gabon 91 Gambia 122 Georgia 45 Germany 5 Ghana 112 Greece 5 Grenada 21 Guatemala 45 Guinea 155 Guinea-Bissau 203 Guyana 64 Haiti 117 Holy See Honduras 41 Hungary 8 Iceland 3 India 85 Indonesia 38 Iran (Islamic Republic of) 38 Iraq 125 Ireland 6 Israel 6 Italy 5 Jamaica 20 Japan 4 Jordan 27 Kazakhstan 73 Kenya 120 Kiribati 65 Korea, Democratic People's Republic of 55 Korea, Republic of 6 Kuwait 12 Kyrgyzstan 68 Lao People's Democratic Republic 83 Latvia 12 Lebanon 31 Lesotho 82 Liberia 235 Libyan Arab Jamahiriya 20 Liechtenstein 5 Lithuania 8 Luxembourg 6 Madagascar 123 Malawi 175 Malaysia 12 Maldives 46 Mali 219 Malta 6 Marshall Islands 59 Mauritania 125 Mauritius 15 Mexico 28 Micronesia (Federated States of) 23 Moldova, Republic of 28 Monaco 5 Mongolia 52 Montenegro*** 15
2004 0 4 4 6 2 3 76 1 0 19 59 16 1 30 8 1 0 2,210 171 50 122 0 1 3 1 5 4 17 159 0 19 3 1 8 17 0 2 4 39 3 0 0 0 87 96 7 0 142 0 0 15 0 62 0 1 0 3 2
2004 281 3,722 193 228 245 3,615 3,069 517 10 1,988 1,562 300 76 1,137 975 481 21 120,155 21,477 5,890 4,274 296 660 2,661 262 5,912 734 1,079 5,557 12 1,763 2,521 235 539 884 99 327 232 621 623 2 154 29 3,064 2,319 2,738 46 2,540 20 7 513 98 10,962 16 211 2 268 611
2004 1 1 11 15 12 1 15 3 10 15 21 23 5 20 14 4 0 19 14 6 18 1 0 1 9 4 12 17 20 12 15 2 4 17 19 1 1 5 23 9 5 1 21 23 4 17 24 0 14 22 4 8 11 16 17 9
2004 0 0 0 1 0 0 11 0 0 3 12 4 0 6 1 0 0 410 25 3 22 0 0 0 0 0 0 3 32 0 3 0 0 1 3 0 0 0 9 0 0 0 18 22 0 0 34 0 0 3 0 5 0 0 1 0
35

PNEUMONIA DEATHS
Total Total number of number of under-five under-five children deaths (000s) (000s) Total number % of under-five of under-five pneumonia deaths deaths due to (000s)a pneumonia
PREVENTION
% of children who are underweight (0-59 months) moderate severe & severe (1996-2004)* (1996-2004)* 9 24 32 24 48 10 40 29 4 24 x 38 7 35 x 5 7 28 6x 6x 3x 27 14 x 13 14 23 2 6x 27 14 x 21 x 26 12 29 17 x 13 10 7 22 19 x 6 2 6 7 5 13 2 14 9 1 4x 12 1 1x 1x 7 2 3 6 0 0x 9 4x 7 2 7x 2 2 1 4 1 % of infants who are exclusively breastfed (<6 months) (1996-2004)* 31 30 15 k 19 68 31 1 17 29 k 16 x, k 59 x, k 25 x 59 22 67 34 12 k 84 56 k 56 31 k 24 k 11 k 4 65 k 9 7 84 16 9 24 81 k 50 41 4 x, k 37 % of one-yearold children immunized against: measles Hib 2004 95 77 78 70 40 73 96 85 84 74 35 99 88 96 98 67 99 99 44 89 89 80 97 95 99 97 98 84 98 95 99 25 98 91 97 57 96 99 64 94 98 94 72 40 81 97 96 59 86 70 94 82 98 89 94 96 96 2004 10 97 90 79 99 93 99 98 99 76 91 95 96 89 95 91 99 98 96 99 93 92 96 98 91 99 -
TREATMENT
% of under-fives with pneumonia taken to an appropriate healthcare provider 1998-2004* 38 55 66 53 26 57 27 33 65 66 x 75 x 51 x 58 55 20 47 27 97 50 75 57 58 60 66 51 68 -
2004 Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Niue Norway Occupied Palestinian Territory Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia*** Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syrian Arab Republic Tajikistan Tanzania, United Republic of Thailand The former Yugoslav Republic of Macedonia 43 152 106 63 30 76 6 6 38 259 197 4 24 13 101 27 24 93 24 29 34 8 5 21 20 21 203 21 14 22 30 4 118 27 137 15 14 283 3 9 4 56 225 67 5 14 91 39 156 4 5 16 118 126 21 14
2004 31 117 105 4 0 60 1 0 6 190 1,049 0 3 1 478 0 2 16 4 18 69 3 1 0 4 32 74 0 0 0 0 0 1 18 57 2 0 69 0 0 0 1 81 73 2 5 106 0 5 0 0 8 22 177 21 0
2004 3,343 3,254 4,716 273 2 3,638 979 276 730 2,775 21,943 0 286 637 302 20,922 2 341 820 814 3,007 9,873 1,830 562 65 1,063 7,052 1,477 4 14 12 26 1 23 3,178 1,820 611 14 925 226 259 87 71 1,446 5,248 2,160 1,631 5,180 46 138 479 361 2,488 839 5,998 5,020 119
2004 14 21 19 3 30 19 1 3 14 25 20 1 7 19 12 11 18 12 14 13 3 2 8 27 6 23 0 1 11 10 21 7 21 9 10 25 9 9 0 9 24 1 1 9 15 11 12 1 1 10 20 21 11 4
2004 4 25 20 0 0 11 0 0 1 48 211 0 0 92 0 0 3 0 2 9 0 0 0 1 2 17 0 0 0 0 0 1 12 0 0 18 0 0 0 0 19 1 0 0 16 0 1 0 0 1 4 37 2 0
36

PNEUMONIA DEATHS
Total Total % of number of number of under-five under-five under-five deaths children deaths due to (000s) (000s) pneumonia Total number of under-five pneumonia deaths (000s)a
PREVENTION
% of children who are underweight (0-59 months) moderate severe & severe (1996-2004)* (1996-2004)* 46 25 7x 4 4 12 23 1 14 x 1x 5x 8 20 x 4 28 46 23 13 15 7 0 1 1 2 5 0 3 0 1 2 1 4 15 2 % of infants who are exclusively breastfed (<6 months) (1996-2004)* 31 18 62 k 2 47 21 13 63 22 34 x, k 19 50 k 7k 15 12 40 33 % of one-yearold children immunized against: measles Hib 2004 55 70 99 95 95 81 97 98 91 99 94 81 93 95 98 48 80 97 76 84 80 2004 94 97 87 94 91 94 94 61 80 -
TREATMENT
% of under-fives with pneumonia taken to an appropriate healthcare provider 1998-2004* 24 30 74 43 41 51 67 57 72 7 47 69 50
2004 Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Yemen Zambia Zimbabwe 80 140 25 20 25 32 103 51 138 18 8 6 8 17 69 40 19 23 111 182 129
2004 4 33 0 0 4 48 11 0 195 7 1 4 33 1 42 0 11 38 92 85 50
2004 160 996 12 89 806 7,236 484 1 5,744 1,930 325 3,398 20,243 283 2,815 30 2,842 7,900 3,581 1,987 1,756
2004 20 17 7 2 8 14 19 14 21 6 5 2 1 5 17 13 6 12 20 22 15
2004 1 6 0 0 0 7 2 0 41 0 0 0 0 0 7 0 1 4 18 19 7
x x x
UNICEF Regions Sub-Saharan Africa Eastern and Southern Africa Western and Central Africa Middle East and North Africa South Asia East Asia and Pacific Latin America and Caribbean CEE/CIS Industrialized countries Developing countries Least developed countries World
171 149 191 56 92 36 31 38 6 87 155 79
4,833 1,992 2,844 539 3,409 1,078 362 212 65 10,411 4,313 10,503
117,346 56,702 60,644 44,067 169,294 146,536 56,526 26,430 54,200 548,486 117,229 614,399
21 21 21 15 21 15 14 13 2 20 23 19
1,022 414 608 82 702 158 50 29 1 2,039 976 2,044
28 29 28 14 46 15 7 5 27 36 26
8 8 9 3 16 1 1 10 11 10
30 41 20 29 38 43 22 36 34 36
66 77 55 89 61 83 92 93 92 74 72 76
91 92 -
41 47 35 66 59 62 ** 52 w 50 54 ** 38 54 **
Data refer to the most recent year available during the period specified in the column heading.
** Excludes China. *** Data represent combined estimates for Serbia and Montenegro. At the time of publication, no separate estimates were available. a k w x Regional and global totals are based on unrounded estimates of under-five deaths. Refers to exclusive breastfeeding for less than four months. Regional average includes data for Brazil from 1996. Indicates data that refer to years or periods other than those specified in the column heading, differ from the standard definition or refer to only part of a country.
Sources: Columns 2-4 and 7-12: UNICEF, The State of the World's Children 2006, UNICEF, New York, December 2005; Columns 5-6: Estimates of childhood pneumonia death based on the work of the CHERG (see Appendix), and appear in World Health Organization, 2006, World Health Statistics 2006, WHO, Geneva.
37
TABLE 2 CARE-SEEKING BEHAVIOUR FOR PNEUMONIA, BY SELECTED BACKGROUND CHARACTERISTICS, 1996-2003

Countries and territories Angola Armenia Azerbaijan Bangladesh Benin Bolivia Botswana Brazil Burkina Faso Burundi Cambodia Cameroon Central African Republic Chad Comoros Congo, Democratic Republic of the Cte d'Ivoire Dominican Republic Egypt Eritrea Ethiopia Gabon Gambia Ghana Guatemala Guinea Guinea-Bissau Guyana Haiti India Indonesia Jordan Kenya Kyrgyzstan Lao Peoples Democratic Republic Lesotho Madagascar Malawi Mali Mauritania Mongolia Morocco Mozambique Myanmar Namibia Nepal Nicaragua Niger Nigeria Peru Philippines Rwanda Sao Tome and Principe Senegal Sierra Leone South Africa Sudan Suriname Swaziland Tajikistan Tanzania, United Republic of Togo Uganda Viet Nam Yemen Zambia Zimbabwe Average (67 countries)
1
Year 2001 2000 2000 2000 2001 2003 2000 1996 2003 2000 2000 2000 2000 2000 2000 2001 2000 2002 2000 2002 2000 2000 2000 2003 2000 2003 2000 2000 2000 2000 2002 2002 2003 1997 2000 2000 2000 2000 2001 2001 2000 2003 1997 2000 2000 2000 2001 2000 2003 2000 2003 2000 2000 2000 2000 1998 2000 2000 2000 2000 1996 2000 2000 2002 1997 2002 1999
% of under-fives with pneumonia taken to an appropriate health care provider 58 26 36 27 35 52 14 46 36 40 37 25 32 22 49 36 38 63 66 44 16 48 75 44 37 33 64 78 26 67 61 78 49 48 36 49 47 27 36 41 78 38 39 48 53 26 58 27 33 58 55 16 47 27 50 75 57 58 60 51 70 30 67 71 32 69 50 46
Area of residence Urban 55 28 29 48 39 56 15 50 65 69 47 48 42 36 64 46 46 64 77 57 41 52 93 53 46 43 76 86 32 78 68 79 63 91 55 52 48 68 56 78 50 65 66 63 41 65 63 34 64 63 24 39 30 57 78 67 49 56 40 81 62 80 75 43 73 55 56 Rural 64 24 38 24 33 45 13 34 32 39 35 19 27 35 46 32 34 63 61 40 14 34 70 40 33 29 57 75 24 64 55 77 46 42 32 48 25 26 26 77 25 28 45 49 25 51 46 32 51 49 14 57 26 48 73 50 61 60 54 67 25 65 71 29 67 48 43
Gender Male 58 24 30 29 36 54 16 47 36 40 40 27 32 22 49 35 37 64 68 44 17 51 71 44 38 32 64 72 25 69 60 82 50 49 36 49 50 26 38 43 78 42 41 50 54 29 58 26 32 57 55 16 46 30 51 75 59 56 58 45 70 35 68 76 33 68 50 46 Female 59 29 42 25 34 49 13 45 36 39 33 22 32 21 49 36 38 63 64 43 14 44 79 44 36 34 65 85 27 63 62 73 48 46 37 50 44 27 33 38 78 34 36 46 53 23 57 28 33 59 54 15 46 23 48 75 56 60 62 55 69 24 65 65 31 70 50 45
Mother's education Source No formal education 55 24 31 41 25 32 38 30 18 26 17 45 32 35 71 60 39 15 47 72 35 38 32 60 47 23 60 63 81 47 20 61 40 22 31 33 71 32 26 40 46 23 45 25 23 45 33 15 55 25 48 73 50 74 58 50 74 28 61 88 29 64 39 43 Primary 58 0 24 49 48 40 51 40 37 22 38 19 51 35 39 64 61 53 17 42 81 38 37 19 81 86 24 71 57 75 49 42 46 47 26 49 51 73 45 46 43 47 32 58 44 42 49 51 15 50 34 36 77 62 52 58 68 35 67 66 44 69 49 47 Secondary1 73 26 35 38 41 61 0 54 84 67 51 42 48 51 71 44 53 63 75 55 37 52 100 57 38 46 74 76 42 79 66 78 52 48 51 56 66 53 77 64 157 51 91 69 61 36 68 55 47 67 58 26 40 42 69 75 69 54 64 51 82 37 77 72 51 74 52 59 MICS 2001 DHS 2000 MICS 2000 DHS 2000 DHS 2001 DHS 2003 MICS 2000 DHS 1996 DHS 2003 MICS 2000 DHS 2000 MICS 2000 MICS 2000 MICS 2000 MICS 2000 MICS 2001 MICS 2000 DHS 2002 DHS 2000 DHS 2002 DHS 2000 DHS 2000 MICS 2000 DHS 2003 DHS 2000 MICS 2003 MICS 2000 MICS 2000 DHS 2000 DHS 2000 DHS 2002 DHS 2002 DHS 2003 DHS 1997 MICS 2000 MICS 2000 MICS 2000 DHS 2000 DHS 2001 DHS 2001 MICS 2000 DHS 2003 DHS 1997 MICS 2000 DHS 2000 DHS 2000 DHS 2001 MICS 2000 DHS 2003 DHS 2000 DHS 2003 DHS 2000 MICS 2000 MICS 2000 MICS 2000 DHS 1998 MICS 2000 MICS 2000 MICS 2000 MICS 2000 DHS 1996 MICS 2000 DHS 2000 DHS 2002 DHS 1997 DHS 2002 DHS 1999
Data from DHS refer to secondary education or higher.
MICS: Multiple Indicator Cluster Survey DHS: Demographic and Health Survey
38
TABLE 3 CAREGIVERS WHO KNOW THAT FAST BREATHING IS A SIGN TO SEEK CARE IMMEDIATELY, BY BACKGROUND CHARACTERISTICS, 1999-2001
Countries and territories Angola Azerbaijan Bolivia Bosnia and Herzegovina Burundi Cameroon Central African Republic Chad Comoros Congo, Democratic Republic of the Cte d'Ivoire Dominican Republic Gambia Guinea-Bissau Guyana Indonesia Lao People's Democratic Republic Lesotho Madagascar Mongolia Myanmar Niger Rwanda Sao Tome and Principe Senegal Sierra Leone Sudan Suriname Swaziland Tajikistan Togo Viet Nam Zambia Average (33 countries) Year 2001 2000 2000 2000 2000 2000 2000 2000 2000 2001 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 1999 % of caregivers who Area of residence Mother's education know that fast breathUrban Rural No formal Primary Secondary ing is a sign to seek education care immediately 37 35 40 37 38 32 5 5 6 4 6 1 1 1 0 1 1 33 32 34 35 32 47 55 47 47 53 63 4 5 4 3 4 5 15 17 14 16 15 13 11 12 11 14 10 10 13 18 10 13 10 16 32 9 5 18 39 17 25 15 33 3 11 10 6 19 7 6 24 26 7 14 48 8 21 7 17 27 11 4 25 55 30 24 22 26 3 13 8 7 9 8 17 26 2 22 57 8 20 9 19 34 7 6 13 29 14 25 13 35 3 10 11 5 20 4 5 27 26 7 12 46 8 22 6 17 68 8 4 17 36 9 21 12 32 3 13 14 5 19 6 5 26 25 12 12 35 9 18 7 17 69 9 6 17 48 16 21 17 34 3 10 11 8 19 5 8 19 36 12 13 30 5 18 7 18 56 13 4 21 57 18 21 31 2 21 9 10 19 9 6 17 26 3 15 49 4 46 8 20 Wealth quintiles Poorest Second Middle Fourth Richest 40 6 1 46 3 17 15 11 36 8 5 11 19 11 38 3 8 11 6 18 3 3 23 24 1 13 54 19 22 6 16 39 6 0 46 3 15 10 13 36 7 8 14 29 16 35 3 12 11 4 21 3 7 24 25 5 12 47 20 7 16 33 4 1 45 5 15 10 10 35 6 3 15 40 14 33 3 13 10 4 20 7 6 20 25 5 14 46 5 21 4 16 36 5 1 48 5 14 12 14 26 10 4 24 46 17 30 3 13 9 5 18 8 6 29 29 5 15 44 25 7 17 37 6 1 51 5 15 11 15 26 16 6 25 65 21 30 2 11 8 7 17 12 6 25 29 15 16 51 13 18 12 19 Source MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS 2001 2000 2000 2000 2000 2000 2000 2000 2000 2001 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 1999
TABLE 4 CAREGIVERS WHO KNOW THAT DIFFICULT BREATHING IS A SIGN TO SEEK CARE IMMEDIATELY, BY SELECTED BACKGROUND CHARACTERISTICS, 1999-2001
Countries and territories Angola Azerbaijan Bolivia Bosnia and Herzegovina Burundi Cameroon Central African Republic Chad Comoros Congo, Democratic Republic of the Cte d'Ivoire Dominican Republic Gambia Guinea-Bissau Guyana Indonesia Lao People's Democratic Republic Lesotho Madagascar Mongolia Myanmar Niger Rwanda Sao Tome and Principe Senegal Sierra Leone Sudan Suriname Swaziland Tajikistan Togo Viet Nam Zambia Average (33 countries) Year 2001 2000 2000 2000 2000 2000 2000 2000 2000 2001 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 1999 % of caregivers who Area of residence Mother's education know that difficult No formal Primary Secondary breathing is a sign to Urban Rural education seek care immediately 31 29 34 29 32 29 11 13 9 7 16 3 4 2 1 2 4 40 42 40 38 42 54 53 54 52 59 61 8 8 8 7 8 9 15 15 15 16 15 13 17 16 17 17 17 16 16 21 14 16 13 19 33 10 19 19 38 25 35 25 29 7 12 14 10 20 6 8 27 35 11 12 56 15 39 8 21 31 14 19 25 57 31 36 34 23 7 12 12 15 8 9 18 36 6 16 64 17 42 10 23 35 9 19 15 26 24 35 22 30 7 11 14 7 20 5 7 30 34 12 10 53 14 38 6 20 70 9 18 17 34 17 34 21 34 6 12 17 9 20 6 7 28 34 18 11 54 16 29 8 21 73 11 19 27 49 25 31 26 28 7 9 14 13 19 6 8 31 36 15 10 48 12 37 8 23 60 18 20 23 63 25 32 28 7 24 13 19 24 7 8 18 36 8 13 56 16 82 8 26 Wealth quintiles Poorest Second Middle Fourth Richest 32 10 2 48 6 17 22 15 36 10 18 16 12 20 29 7 11 14 6 19 4 7 25 31 10 10 60 33 35 7 19 30 12 3 52 10 16 15 14 37 8 23 11 25 25 34 6 13 12 7 19 4 9 27 34 8 10 57 41 6 20 28 11 3 58 8 14 13 17 38 9 17 17 40 23 27 8 12 20 8 18 5 8 29 36 9 12 51 13 41 4 20 33 10 2 55 9 15 16 15 29 12 18 24 48 27 28 7 11 13 9 22 5 8 32 39 9 13 52 45 8 21 30 12 5 58 8 12 16 18 28 17 20 27 67 31 25 6 11 9 14 28 14 6 21 36 18 17 59 30 37 13 23 Source MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS MICS 2001 2000 2000 2000 2000 2000 2000 2000 2000 2001 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 2000 1999
39
TABLE 5 CHILDREN UNDER FIVE WITH PNEUMONIA TREATED WITH ANTIBIOTICS (MAINLY FROM THE EARLY 1990s), BY SELECTED BACKGROUND CHARACTERISTICS
Countries and territories Brazil Brazil Burkina Faso Burundi Cameroon Colombia Colombia Dominican Republic Dominican Republic Egypt Egypt Ghana Ghana India Kenya Liberia Madagascar Malawi Mali Morocco Namibia Niger Nigeria Pakistan Paraguay Philippines Philippines Rwanda Senegal Tanzania, United Republic of Turkey Yemen Zambia Average (27 countries)1
1
Year 1991 1996 1992-93 1987 1991 1986 1990 1991 1996 1992 2000 1993 1998 1992-93 1993 1986 1992 1992 1987 1992 1992 1992 1990 1990-91 1992 1993 1998 1992 1992-93 1992 1993 1991-92 1992
% of under-fives with pneumonia treated with antibiotics 13 15 12 1 13 5 30 29 10 25 75 24 16 33 22 2 20 24 2 7 23 9 23 16 29 44 36 4 18 22 22 7 14 19
Area of residence Urban 14 16 27 3 19 7 30 29 12 35 82 38 13 37 24 2 25 38 3 11 26 25 35 24 34 49 43 18 21 22 29 12 23 24 Rural 13 12 9 1 10 2 31 28 8 18 73 21 17 33 22 2 19 22 2 5 22 7 21 13 24 40 32 3 17 22 16 6 8 17
Gender Male 14 14 12 1 14 6 31 30 10 29 76 23 14 34 25 2 20 22 4 8 22 10 24 16 33 47 39 4 18 20 23 7 14 19 Female 13 16 12 1 12 4 30 27 10 20 75 26 18 32 20 3 20 26 0 5 24 9 23 16 23 41 33 3 19 23 22 6 14 18
Mother's education Source No formal education 9 14 10 1 3 3 14 20 6 18 70 16 14 32 20 2 17 23 1 5 21 9 21 14 17 29 30 3 17 16 22 6 9 15 Primary 14 11 19 1 17 6 33 29 12 27 71 34 17 32 23 2 16 24 12 10 23 9 27 20 28 39 28 4 25 24 20 16 12 20 Secondary1 22 19 61 1 27 5 30 31 9 36 83 13 18 40 24 3 33 27 0 21 25 26 26 28 34 49 42 14 24 32 33 32 29 27 DHS 1991 DHS 1996 DHS 1992-93 DHS 1987 DHS 1991 DHS 1986 DHS 1990 DHS 1991 DHS 1996 DHS 1992 DHS 2000 DHS 1993 DHS 1998 DHS 1992-93 DHS 1993 DHS 1986 DHS 1992 DHS 1992 DHS 1987 DHS 1992 DHS 1992 DHS 1992 DHS 1990 DHS 1990-91 DHS 1992 DHS 1993 DHS 1998 DHS 1992 DHS 1992-93 DHS 1992 DHS 1993 DHS 1991-92 DHS 1992
Average is based on the latest available data for 27 countries.
40
REGIONAL SUMMARIES
Regional averages presented in this report, including Statistical Table 1, are calculated using data from the countries and territories as grouped below.
Sub-Saharan Africa
Angola; Benin; Botswana; Burkina Faso; Burundi; Cameroon; Cape Verde; Central African Republic; Chad; Comoros; Congo; Congo, Democratic Republic of the; Cte d'Ivoire; Equatorial Guinea; Eritrea; Ethiopia; Gabon; Gambia; Ghana; Guinea; Guinea-Bissau; Kenya; Lesotho; Liberia; Madagascar; Malawi; Mali; Mauritania; Mauritius; Mozambique; Namibia; Niger; Nigeria; Rwanda; Sao Tome and Principe; Senegal; Seychelles; Sierra Leone; Somalia; South Africa; Swaziland; Tanzania, United Republic of; Togo; Uganda; Zambia; Zimbabwe.
Middle East and North Africa

Algeria; Bahrain; Djibouti; Egypt; Iran (Islamic Republic of ); Iraq; Jordan; Kuwait; Lebanon; Libyan Arab Jamahiriya; Morocco; Occuped Palestinian Territory; Oman; Qatar; Saudi Arabia; Sudan; Syrian Arab Republic; Tunisia; United Arab Emirates; Yemen.
South Asia
Afghanistan; Bangladesh; Bhutan; India; Maldives; Nepal; Pakistan; Sri Lanka.
East Asia and Pacific

Brunei Darussalam; Cambodia; China; Cook Islands; Fiji; Indonesia; Kiribati; Korea, Democratic People's Republic of; Korea, Republic of; Lao People's Democratic Republic; Malaysia; Marshall Islands; Micronesia (Federated States of ); Mongolia; Myanmar; Nauru; Niue; Palau; Papua New Guinea; Philippines; Samoa; Singapore; Solomon Islands; Thailand; Timor-Leste; Tonga; Tuvalu; Vanuatu; Viet Nam.
Latin America and Caribbean

Antigua and Barbuda; Argentina; Bahamas; Barbados; Belize; Bolivia; Brazil; Chile; Colombia; Costa Rica; Cuba; Dominica; Dominican Republic; Ecuador; El Salvador; Grenada; Guatemala; Guyana; Haiti; Honduras; Jamaica; Mexico; Nicaragua; Panama; Paraguay; Peru; Saint Kitts and Nevis; Saint Lucia; Saint Vincent and the Grenadines; Suriname; Trinidad and Tobago; Uruguay; Venezuela (Bolivarian Republic of ).
CEE/CIS
Albania; Armenia; Azerbaijan; Belarus; Bosnia and Herzegovina; Bulgaria; Croatia; Georgia; Kazakhstan; Kyrgyzstan; Moldova, Republic of; Montenegro; Romania; Russian Federation; Serbia; Tajikistan; the former Yugoslav Republic of Macedonia; Turkey; Turkmenistan; Ukraine; Uzbekistan.
Industrialized countries
Andorra; Australia; Austria; Belgium; Canada; Cyprus; Czech Republic; Denmark; Estonia; Finland; France; Germany; Greece; Holy See; Hungary; Iceland; Ireland; Israel; Italy; Japan; Latvia; Liechtenstein; Lithuania; Luxembourg; Malta; Monaco; Netherlands; New Zealand; Norway; Poland; Portugal; San Marino; Slovakia; Slovenia; Spain; Sweden; Switzerland; United Kingdom; United States.
Developing countries
Afghanistan; Algeria; Angola; Antigua and Barbuda; Argentina; Armenia; Azerbaijan; Bahamas; Bahrain; Bangladesh; Barbados; Belize; Benin; Bhutan; Bolivia; Botswana; Brazil; Brunei Darussalam; Burkina Faso; Burundi; Cambodia; Cameroon; Cape Verde; Central African Republic; Chad; Chile; China; Colombia; Comoros; Congo; Congo, Democratic Republic of the; Cook Islands; Costa Rica; Cte d'Ivoire; Cuba; Cyprus; Djibouti; Dominica; Dominican Republic; Ecuador; Egypt; El Salvador; Equatorial Guinea; Eritrea; Ethiopia; Fiji; Gabon; Gambia; Georgia; Ghana; Grenada; Guatemala; Guinea; Guinea-Bissau; Guyana; Haiti; Honduras; India; Indonesia; Iran (Islamic Republic of ); Iraq; Israel; Jamaica; Jordan; Kazakhstan; Kenya; Kiribati; Korea, Democratic People's Republic; Korea, Republic of; Kuwait; Kyrgyzstan; Lao People's Democratic Republic; Lebanon; Lesotho; Liberia; Libyan Arab Jamahiriya; Madagascar; Malawi; Malaysia; Maldives; Mali; Marshall Islands; Mauritania; Mauritius; Mexico; Micronesia (Federated States of ); Mongolia; Morocco; Mozambique; Myanmar; Namibia; Nauru; Nepal; Nicaragua; Niger; Nigeria; Niue; Occuped Palestinian Territory; Oman; Pakistan; Palau; Panama; Papua New Guinea; Paraguay; Peru; Philippines; Qatar; Rwanda; Saint Kitts and Nevis; Saint Lucia; Saint Vincent and the Grenadines; Samoa; Sao Tome and Principe; Saudi Arabia; Senegal; Seychelles; Sierra Leone; Singapore; Solomon Islands; Somalia; South Africa; Sri Lanka; Sudan; Suriname; Swaziland; Syrian Arab Republic; Tajikistan; Tanzania, United Republic of; Thailand; Timor-Leste; Togo; Tonga; Trinidad and Tobago; Tunisia; Turkey; Turkmenistan; Tuvalu; Uganda; United Arab Emirates; Uruguay; Uzbekistan; Vanuatu; Venezuela (Bolivarian Republic of ); Viet Nam; Yemen; Zambia; Zimbabwe.
Least developed countries

Afghanistan; Angola; Bangladesh; Benin; Bhutan; Burkina Faso; Burundi; Cambodia; Cape Verde; Central African Republic; Chad; Comoros; Congo, Democratic Republic of; Djibouti; Equatorial Guinea; Eritrea; Ethiopia; Gambia; Guinea; Guinea-Bissau; Haiti; Kiribati; Lao People's Democratic Republic; Lesotho; Liberia; Madagascar; Malawi; Maldives; Mali; Mauritania; Mozambique; Myanmar; Nepal; Niger; Rwanda; Samoa; Sao Tome and Principe; Senegal; Sierra Leone; Solomon Islands; Somalia; Sudan; Tanzania, United Republic of; Timor-Leste; Togo; Tuvalu; Uganda; Vanuatu; Yemen; Zambia.
PNEUMONIA KILLS MORE CHILDREN THAN ANY OTHER ILLNESS MORE THAN AIDS, MALARIA AND MEASLES COMBINED. EFFECTIVE INTERVENTIONS TO REDUCE PNEUMONIA DEATHS ARE AVAILABLE BUT REACH TOO FEW CHILDREN. MORE THAN A MILLION LIVES COULD BE SAVED IF PREVENTION AND TREATMENT INTERVENTIONS WERE IMPLEMENTED UNIVERSALLY. PREVENTING CHILDREN UNDER FIVE FROM DEVELOPING PNEUMONIA IN THE FIRST PLACE IS KEY.
UNITED NATIONS CHILDREN'S FUND

3 UN Plaza, New York, New York 10017 USA
WORLD HEALTH ORGANIZATION

Avenue Appia 20, 1211 Geneva 27, Switzerland
ISBN-13: 978-92-806-4048-9 ISBN-10: 92-806-4048-8 September 2006

Pneumonia The Forgotten Killer of Children

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Pneumonia The Forgotten Killer of Children

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PNEUMONIA

Cover photo: UNICEF/HQ05-0531/Rachel Donnan

Pneumonia: Who suffers, Who dies?.....................................................................10

Key actions needed to reduce pneumonia deaths...............................................22

The cost of reducing pneumonia deaths ..............................................................28

Pneumonia: A forgotten pandemic .......................................................................29

Statistical tables ......................................................................................................34

COUNTING UNDER-FIVE DEATHS FROM PNEUMONIA

FIGURE 1 PNEUMONIA IS THE LEADING KILLER OF CHILDREN WORLDWIDE

Millennium Development Goals

Undernutrition is implicated in 53% of all deaths among children under five.

FIGURE 2 PNEUMONIA IS A MAJOR CAUSE OF CHILD DEATHS IN EVERY REGION

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

TERMINOLOGY USED IN THIS REPORT

WHAT ARE THE

FIGURE 3 PATHOGEN-SPECIFIC CAUSES OF SEVERE PNEUMONIA CASES

Streptococcus pneumoniae (bacterium) Haemophilus influenzae (bacterium)

WHY ARE CHILDREN

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

WHO SUFFERS, WHO DIES?

Sudan Viet Nam Total

NOTE: Country-level estimates do not add up to the total due to rounding.

FIGURE 6 INCIDENCE OF PNEUMONIA IS HIGHEST IN SOUTH ASIA AND SUB-SAHARAN AFRICA

Based on data from 134 countries, by UNICEF region, 2004.

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

FIGURE 7 ESTIMATED INCIDENCE OF CHILDHOOD PNEUMONIA WORLDWIDE, 2004

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

LEVELS AND TRENDS IN KNOWLEDGE AND TREATMENT

SEEK appropriate care

TREAT appropriately with antibiotics

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

RECOGNITION OF PNEUMONIAS DANGER SIGNS

Data from 33 MICS, 1999-2001 (see statistical tables 3 and 4).

FIGURE 9 ONLY HALF OF CHILDREN WITH PNEUMONIA TAKEN TO AN APPROPRIATE PROVIDER

See statistical table 1.

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

BOYS AND GIRLS SIMILARLY TAKEN TO APPROPRIATE CARE

RURAL CHILDREN MORE OFTEN LACK APPROPRIATE PROVIDER

CHILDREN OF POORLY EDUCATED MOTHERS MORE OFTEN LACK APPROPRIATE CARE

POORER CHILDREN MORE OFTEN LACK APPROPRIATE CARE

Trends in care-seeking behaviour

UNICEF/ HQ98-0488/Alejandro Balaguer

UNICEF/ HQ04-0264/Christine Nesbitt

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

ANTIBIOTIC TREATMENT FOR PNEUMONIA

FIGURE 11 CHILDREN UNDER FIVE WITH PNEUMONIA WHO RECEIVED ANTIBIOTICS

19% 24% 17% 19% 18% 15% 20% 27%

UNICEF/HQ05-1718/Niclas UNICEF/HQ05-1718/NiclasRyberg Ryberg

NEEDED TO REDUCE PNEUMONIA DEATHS

CLASSIFY AS Severe pneumonia

PNEUMOCOCCAL CONJUGATE VACCINE

THE COST OF REDUCING PNEUMONIA DEATHS

UNICEF/ HQ05-0336/Josh Estey

UNICEF/ HQ06-0042/Indrias Getachew

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

KNOWLEDGE OF PNEUMONIAS DANGER SIGNS

CARE-SEEKING FOR PNEUMONIA

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

PNEUMONIA: THE FORGOTTEN KILLER OF CHILDREN

TABLE 1 KEY PNEUMONIA INDICATORS: MORTALITY, PREVENTION AND TREATMENT

Countries and territories

Under-five mortality rate